Participant Registration

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Registro en Español

Presbyterian Church of Jackson Hole

Location

1251 S Park Loop Rd

Jackson, WY 83001

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Contact Diane McGee:

307-699-2080

dmcgee@pcjh.org

First, Tell Us About Yourself:

Parent Information

Emergency Care Authorization Form - Required

Please print, sign and give to Megan or Diane OR scan & email signed waiver to dmcgee@pcjh.org

Find it here: https://vbspro.events/p/events/da78b9 and scroll down to "Documents" "Learn More"

First Name

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Last Name

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Relationship to Child

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Address 1

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Address 2

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City

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State/Province

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ZIP/Postal Code

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Contact Phone 1

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Contact Phone 2

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Parent / Guardian #2

Padre / Guardián #2

First Name & Last Name

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Relationship to Child

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Text Message Phone

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Emergency Contacts

Contactos de Emergencia

Emergency Contact Name

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Emergency Contact Relationship

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Emergency Contact Phone

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Are you interested in afternoon care? Noon - 4pm (limited spaces)

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Comments

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Click here for your FREE Friends With God Kids Activity Pack

By checking the box you will be emailed your Free Friends With God Kids Activity Pack.

You are also agreeing to receive emails about family resources from Lifetree. You can unsubscribe at any time. We value your privacy. Your information will not be shared with a third party. Lifetree is a division of Group Publishing, the creators of Group VBS and other faith-building resources. Click to learn more about Lifetree.

Tell Us About Your Participant

First Name

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Last Name

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Gender

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Date Of Birth

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Grade Entering

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School

Multiple selections are allowed.

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Shirt Size

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Health

Allergies

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Medical Concerns

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Physician Name & Phone Number

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Helpful/Relevant Social & Mental Conditions & Information

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Insurance

Medical Group # & Patient/User ID #

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Dental Group # & Patient/User ID #

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Sunscreen & Bug Spray Permission: As the parent or guardian of the named camper, I give permission for PCJH VBA Staff & volunteers to apply sunscreen and/or bug repellent that they have OR I will supply products and application as specified below.

This field is required.

Photography and Video Permission: Please indicate “yes or no” “below: I give the staff or volunteers at PCJH permission to photograph and/or videotape my child(ren), and to display such photos and/or videos in PCJH publications, displays or websites.

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Individuals Authorized to Take Child From Facility (other than parent/guardian)

First Name & Last Name

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Relationship to Child

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Cell Phone

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Comments

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